Is Consumer Response to Plain/Standardised Tobacco ...

Is Consumer Response to Plain/Standardised Tobacco

Packaging Consistent with Framework Convention on

Tobacco Control Guidelines? A Systematic Review of

Quantitative Studies

Martine Stead1*, Crawford Moodie1, Kathryn Angus1, Linda Bauld1, Ann McNeill2, James Thomas3,

Gerard Hastings1, Kate Hinds3, Alison O¡¯Mara-Eves3, Irene Kwan3, Richard I. Purves1, Stuart L. Bryce1

1 Institute for Social Marketing & Cancer Research United Kingdom Centre for Tobacco Control Research and United Kingdom Centre for Tobacco and Alcohol Studies,

University of Stirling, Stirling, United Kingdom, 2 Addictions Department, Institute of Psychiatry, King¡¯s College London, United Kingdom Centre for Tobacco and Alcohol

Studies, London, United Kingdom, 3 Evidence for Policy and Practice Information and Co-ordinating-Centre, Social Science Research Unit, Institute of Education, London,

United Kingdom

Abstract

Background and Objectives: Standardised or ¡®plain¡¯ tobacco packaging was introduced in Australia in December 2012 and

is currently being considered in other countries. The primary objective of this systematic review was to locate, assess and

synthesise published and grey literature relating to the potential impacts of standardised tobacco packaging as proposed

by the guidelines for the international Framework Convention on Tobacco Control: reduced appeal, increased salience and

effectiveness of health warnings, and more accurate perceptions of product strength and harm.

Methods: Electronic databases were searched and researchers in the field were contacted to identify studies. Eligible studies

were published or unpublished primary research of any design, issued since 1980 and concerning tobacco packaging.

Twenty-five quantitative studies reported relevant outcomes and met the inclusion criteria. A narrative synthesis was

conducted.

Results: Studies that explored the impact of package design on appeal consistently found that standardised packaging

reduced the appeal of cigarettes and smoking, and was associated with perceived lower quality, poorer taste and less

desirable smoker identities. Although findings were mixed, standardised packs tended to increase the salience and

effectiveness of health warnings in terms of recall, attention, believability and seriousness, with effects being mediated by

the warning size, type and position on pack. Pack colour was found to influence perceptions of product harm and strength,

with darker coloured standardised packs generally perceived as containing stronger tasting and more harmful cigarettes

than fully branded packs; lighter coloured standardised packs suggested weaker and less harmful cigarettes. Findings were

largely consistent, irrespective of location and sample.

Conclusions: The evidence strongly suggests that standardised packaging will reduce the appeal of packaging and of

smoking in general; that it will go some way to reduce consumer misperceptions regarding product harm based upon

package design; and will help make the legally required on-pack health warnings more salient.

Citation: Stead M, Moodie C, Angus K, Bauld L, McNeill A, et al. (2013) Is Consumer Response to Plain/Standardised Tobacco Packaging Consistent with

Framework Convention on Tobacco Control Guidelines? A Systematic Review of Quantitative Studies. PLoS ONE 8(10): e75919. doi:10.1371/journal.pone.0075919

Editor: Philippa Middleton, The University of Adelaide, Australia

Received May 13, 2013; Accepted August 19, 2013; Published October 16, 2013

Copyright: ? 2013 Stead et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits

unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This review was funded by the Department of Health through the Public Health Research Consortium (PHRC). The views expressed are those of the

authors and not necessarily those of the Department of Health. Information about the wider programme of the PHRC is available from .

uk. The University of Stirling and King¡¯s College London authors are members of the United Kingdom Centre for Tobacco Control Studies ().

Funding from the British Heart Foundation, Cancer Research United Kingdom, the Economic and Social Research Council, the Medical Research Council and the

National Institute of Health Research, under the auspices of the United Kingdom Clinical Research Collaboration, is gratefully acknowledged. The funders had no

role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests: AM, JT, KH, AO and IK state no competing interests. The Institute for Social Marketing and Centre for Tobacco Control Studies at the

University of Stirling receive research funding from Cancer Research United Kingdom. MS, CM, KA, LB, RIP and SLB state no competing interests other than the

institutional funding received from Cancer Research United Kingdom. GH has served as an expert witness in four cases: 1) in the United Kingdom for the plaintiff

(McTear) versus the tobacco industry; and for 2) the United Kingdom Department of Health, 3) the Irish Government and 4) the Norwegian Government¡¯s defence

of suits by the tobacco industry. GH states no financial competing interests. This does not alter the authors¡¯ adherence to all the PLOS ONE policies on sharing

data and materials.

* E-mail: martine.stead@stir.ac.uk

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Consumer Response to Standardised Tobacco Packs

The primary aim of the systematic review was to assess the

impact of standardised tobacco packaging, based upon the

potential benefits of standardised packaging proposed by the

guidelines for Articles 11 and 13 of the FCTC [10,11], on: 1) pack

and product appeal; 2) prominence of health warnings; 3) use of

packaging elements that may mislead about product harm.

Secondary aims were to assess any other potential impacts of

standardised packaging not identified by the FCTC, assess the

facilitators and barriers to plain packaging having an impact, and

examine differences in response to standardised packaging, if any,

by gender, age, socio-economic status and ethnicity (see the review

Protocol [18]). This article reports on the findings for the primary

aim of the systematic review and any demographic sub-group

differences. The findings for the secondary aims of the review are

reported elsewhere (see [19]).

Introduction

Smoking is the largest single cause of avoidable morbidity and

mortality in much of the world, being a risk factor for six of the

eight leading causes of death globally [1] and responsible for

approximately five million deaths a year [2]. Smoking is the risk

factor associated with the most deaths per annum in high-income

countries and globally only high blood pressure is a greater risk

factor [3]. Smoking harms nearly every organ of the body [4], with

the adverse health effects of smoking extending beyond the

individual smoker, with over 600,000 non-smokers estimated to

die each year from exposure to second-hand smoke [5]. Annual

public healthcare expenditure in the European Union for treating

smoking related illness is estimated to be in excess of 25 billion

euros. The European Commission estimates that the life years lost

due to smoking related illness corresponds to 517 billion euros a

year [6].

In response to these risks the first global public health treaty, the

Framework Convention on Tobacco Control (FCTC), was

formally initiated at the 48th World Health Assembly in 1995. It

came into force in 2005 and is now one of the most widely

embraced treaties in the history of the United Nations, with almost

90% of the global population covered through 177 Parties to the

Convention, as of August 2013. The objective of the FCTC, as

outlined in Article 3, is ¡®¡®to protect present and future generations

from the devastating health, social, environmental and economic

consequences of tobacco consumption and exposure to tobacco

smoke¡¯¡¯ [7]. To meet this goal the FCTC asserts the importance of

both supply issues (e.g. combating illicit tobacco) and also demand

reduction measures, including protection from exposure to

tobacco smoke, regulation of the contents of tobacco products,

cessation, and education, communication, training and public

awareness.

Two of these demand reduction measures are controls on

tobacco advertising, promotion and sponsorship, and packaging

and labelling, identified as priority areas during the development

of the FCTC [8,9]. As a growing number of countries have

adopted complete or comprehensive bans on tobacco advertising

and promotion, there has been increased regulatory attention paid

to the role of packaging as a marketing and communications tool.

The guidelines for Articles 11 and 13 of the FCTC recommend

Parties introduce plain tobacco packaging [10,11], which involves

standardising pack appearance. In December 2012, the Australian

Government became the first to require that all tobacco products

be in standardised or ¡®plain¡¯ packs. While the Australian High

Court ruled in favour of the decision to introduce standardised

packaging in Australia in August 2012, a Notice of Arbitration

under Australia¡¯s Bilateral Investment Treaty with Hong Kong

brought by Philip Morris Asia in November 2011, and the World

Trade Organization dispute settlement (WT/DS434) brought by

Ukraine in March 2012, remain outstanding. Also in December

2012, the European Commission announced the scope of a draft

Tobacco Products Directive, which does not provide a panEuropean Union mandate for standardised packaging but allows

member countries to introduce standardised packaging. Most

recently, in February 2013, the New Zealand Government

announced, in principle, plans to introduce standardised packaging, as did the Scottish Government in March 2013 and Irish

Government in May 2013.

There have been a small number of recent reviews of literature

on standardised packaging [12¨C17]. However, none of these

reviews adopted a systematic approach and only two were

published in peer-reviewed journals.

PLOS ONE |

Methods

The review aimed to include all standardised tobacco packaging

primary research studies, conducted since 1980. Twenty-one

electronic databases from the fields of health, public health, social

science and social care were searched in June and July 2011 as

were fourteen websites, including Google Scholar and the Legacy

Tobacco Documents Library, a digital archive of tobacco industry

documents (see Appendix S1 for a list of the databases and

websites, as well as an example of the search strategy). Contact was

also made with academics and market research groups known to

have conducted research on standardised packaging, either

currently or in the past; academics involved in research concerning

tobacco packaging, although not specifically standardised packaging; and non-governmental organisations which have written on

the topic of standardised packaging; two people known to be

collating standardised packaging research within the European

Commission and the Australian Department of Health and Ageing

respectively. A cut-off date of the 31st August 2011 was set for

receipt of full text papers for screening. We did not limit our

studies to papers in English, and a number of French studies were

included. Studies were managed by the EPPI-Centre¡¯s online

review software (EPPI-Reviewer 4.0) [20].

A total of 4,518 citations were screened (using the inclusion

criteria: from or after 1980; about human populations; about

tobacco; about packaging; and primary research) from which 169

papers were retrieved for full text screening by two reviewers.

From these, 41 papers were included for data extraction.

Data extraction

All studies were coded using a standard classification system

[21] and further codes were added to capture information specific

to this review. A coding tool (see Appendix S2) was developed and

data extracted for each study by two researchers, one from the

EPPI-Centre (KH/IK) and one from the University of Stirling

(KA/RP/SB). Data were extracted on: study aims and design; the

sample studied; sampling strategy, recruitment and consent

processes; data collection and analysis; and findings (extracted

both as a narrative and as odds ratios and standardized mean

differences [22]). Authors were contacted for additional information or for clarification if needed.

Quality appraisal and relevance checking

Different quality criteria were used for each study design,

following principles of good practice for critical appraisal of

primary research [23,24]. For surveys, we used a tool developed by

Wong et al. [25], and for interventions, we used criteria devised by

Shepherd et al. [26]. The relevance of each study was then

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Consumer Response to Standardised Tobacco Packs

Figure 1. Literature search and study selection process.

doi:10.1371/journal.pone.0075919.g001

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Consumer Response to Standardised Tobacco Packs

In four studies, three using an experimental between-subjects

design [36,48,49] and one an experimental within-subjects design

[42], comparisons were made of the perceived attractiveness of

branded packs against a series of packs retaining progressively

fewer original brand elements (brand name font, colour, descriptor

terms such as ¡®smooth¡¯, and so on). These studies consistently

found that packs became less attractive the plainer they became.

In three studies conducted with young women in Canada [33],

the UK [39] and the USA [40], an experimental design was used

in which current branded female¨Coriented packs (i.e. where

packaging was oriented towards women) were compared in

attractiveness with current branded female-oriented packs but

with descriptors (terms such as ¡®slims¡¯) removed, standardised

brown packs for the same female-oriented brands, and current

branded packs not oriented towards women. These studies

consistently reported that standardised packs were rated as less

appealing than branded female-oriented packs, female-oriented

packs with descriptors removed, and packs not targeted at women.

Studies conducted with adolescents consistently reported that

young people responded negatively to standardised packaging. In

a mixed methods non-experimental study with 12¨C17 year olds in

Canada [31], standardised packs were rated significantly

(p,0.001) worse on the ratings ugly/attractive, boring/exciting,

old-fashioned/modern, awful/nice, dull/colourful and nerdy/

cool, while 10¨C17 year olds in Scotland rated a standardised pack

as unattractive (91%), uncool (87%) and a pack you would not like

to be seen with (88%) in a non-experimental online survey [44].

Perceived quality and taste. The twelve studies which

examined perceptions of the quality of cigarettes in standardised

packs, using outcomes such as ¡®quality of tobacco¡¯, ¡®taste¡¯,

¡®richness¡¯ and ¡®satisfying¡¯, consistently found that cigarettes in

standardised packs were perceived as being of lower quality than

those in branded packs even when the same brand name appeared

on the packs (see Table 1, fourth column). In three experimental

studies which compared perceptions of packs with progressively

more original branding elements removed [36,48,49], ratings of

quality became more negative as packs became more standardised.

For example, in an experimental between-subjects design study

conducted with 14¨C17 year olds in Australia, ratings of cigarettes

as ¡®rich¡¯, ¡®satisfying¡¯ and ¡®high quality¡¯ were lower (p,0.001) for

the standardised pack compared with the fully branded pack, and

the differences increased as more original branding elements were

removed [36]. Similarly, in an experimental between-subjects

design study with 16¨C26 year old female smokers and non-smokers

in Brazil, participants rated standardised packs with descriptors as

less smooth (p,0.05) and poorer tasting (p,0.001) than branded

packs, with the difference in rating increasing as descriptors were

removed from the standardised packs [49].

Smoker identity. An important aspect of cigarette pack

appeal is the extent to which the pack is associated with a desirable

smoker identity, and this was examined in thirteen studies.

Measures for assessing identity included ratings of packs on

projected personality attributes, asking participants whether a pack

was aimed at them or someone like them, and visual experiments

which measured the strength of association between specific

brands and person types. Standardised packs were consistently

rated more negatively on desirable personality attributes than

branded packs (see Table 1, fifth column). In two experimental

between-subjects design studies, 16¨C26 year old females in Brazil

rated standardised packs more negatively than branded packs on

the attributes ¡®female¡¯, ¡®stylish¡¯ and ¡®sophisticated¡¯ (p,0.05) [49],

while teenagers in Australia rated standardised pack smokers more

negatively than branded pack smokers in terms of being ¡®young¡¯,

¡®masculine¡¯, ¡®sociable¡¯ and ¡®confident¡¯ [36]. In a visual experiment

assessed based on their aims, sample, methods for data collection

and analysis and findings. After this stage, two studies were

excluded having incomplete analyses, and two excluded on

grounds of methodological quality resulting in 37 included studies

for the full systematic review [19].

This article reports on a sub-set of 25 studies from the full

systematic review which report outcomes relating to the potential

benefits identified in the guidelines for Articles 11 and 13 of the

FCTC, as described above. Eight studies that employed qualitative

methods only and four studies that examined other outcomes, such

as facilitators and barriers to the introduction of standardised

packaging policies or its impact on smoking-related attitudes,

beliefs and behavioural intentions, are not included in this paper

but their results are outlined elsewhere [19]. We focused on the

studies employing quantitative methods only in order to facilitate

comparisons and synthesis of results between studies. The

literature search and study selection process is shown in Figure 1.

Synthesis

A framework that encompassed the range of impacts measured

was constructed in order to structure the findings [27]. Impacts

were organised into overarching themes under which findings are

summarised narratively, namely:

N

N

N

Impact of standardised packaging on appeal

Impact of standardised packaging on the salience and

effectiveness of health warnings

Impact of standardised packaging on perceptions of product

strength and harm.

A narrative synthesis was presented with care taken to avoid

¡®vote counting¡¯ of statistically significant results; vote counting fails

to take account of the relative size of studies, their methodological

quality or the magnitude of their effects [28]. Both statistical

significance and directions of effect were examined for each study.

Results

The 25 quantitative studies reported in this article comprised 18

cross-sectional surveys with an experimental (between- or withinsubjects) design, three cross-sectional surveys without an experimental design, three mixed methods studies and one intervention

study. Full details and summary findings are given in Table S1.

Appeal of cigarettes, packs and brands

Twenty-one studies [29¨C49] in the review examined whether

and how standardised packs impact on the appeal of cigarettes,

packs or brands. The measures of appeal were grouped into three

categories, attractiveness of the pack, perceived quality and taste of

the cigarettes, and smoker identity ¨C the extent to which the pack

was associated with a desirable smoker identity or positive

personality attributes. For all 21 studies, Table 1 shows the nature

of the comparison made in the study and the direction of effect.

¡®Favours branded packs¡¯ means that respondents found the

branded packs more attractive than standardised packs or thought

that they contained better quality cigarettes or that positive smoker

identity attributes were stronger for branded packs than for

standardised packs.

Attractiveness. Twenty-one studies examined perceptions or

ratings of the attractiveness of standardised packs. Findings were

highly consistent, with all studies reporting that standardised packs

were considered less ¡®appealing¡¯, ¡®attractive¡¯, ¡®cool¡¯, ¡®stylish¡¯ and

¡®attention-grabbing¡¯ than branded equivalent packs, by both adults

and children (see Table 1, third column).

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Consumer Response to Standardised Tobacco Packs

Table 1. Direction of effect: Attractiveness, quality and smoker identity.

Direction of effect

Study

Type of Comparison

Attractiveness

Quality

Bansal-Travers 2011 [29]

Branded vs. standardised

Favours branded

Favours branded

Bondy 1996 [30]

Branded vs. standardised

Favours branded

Centre for Health Promotion 1993 [31]

Branded vs. standardised

Favours branded

Donovan 1993 [32]

Branded vs. standardised

Favours branded

Doxey 2011 [33]

Branded vs. standardised

Gallopel-Morvan 2010 [34]

Gallopel-Morvan 2012 [35]

Smoker Identity

Favours branded

Favours branded

Favours branded

Favours branded

Favours branded

Branded vs. standardised

Favours branded

Favours branded

Favours branded

Branded vs. standardised

Favours branded

Germain 2010 [36]

Branded vs. standardised

Favours branded

Favours branded

Favours branded

Goldberg 1995 [37]

Branded vs. standardised

Hammond 2009 [38]

Branded vs. standardised

Favours branded

Favours branded

Hammond 2013 [39]

Branded vs. standardised

Favours branded

Favours branded

Favours branded

Hammond 2011 [40]

Branded vs. standardised

Favours branded

Favours branded

Favours branded

Hoek 2009 [41]

Branded vs. standardised

Favours branded

Favours branded

Favours branded

Hoek 2011 [42]

Branded vs. standardised

Favours branded

Moodie 2011 [43]

Branded vs. standardised

Favours branded

Favours branded

Moodie 2012 [44]

Different colours of

standardised packs

Standardised rated

negatively

Favours lighter-coloured

standardised

Rootman 1995 [45]

Branded vs. standardised

Favours branded

Swanson 1997 [46]

Branded vs. standardised

Thrasher 2011 [47]

Branded vs. standardised

Favours branded

Wakefield 2008 [48]

Branded vs. standardised

Favours branded

Favours branded

Favours branded

White 2011 [49]

Branded vs. standardised

Favours branded

Favours branded

Favours branded

Standardised rated negatively

Favours branded

Favours branded

An empty cell indicates that the study did not address the outcome in question.

doi:10.1371/journal.pone.0075919.t001

believability of the warnings [34,36,37,43,45,50,51]. Table 2

illustrates the direction of effect for the results in each of these

studies, with ¡®favours standardised packs¡¯ meaning that standardised packaging increased the salience and effectiveness of health

warnings in terms of recall, attention, believability and seriousness.

The overall direction of effect was less consistent than for ¡®Appeal¡¯,

but overall (four of seven studies) tended to favour standardised

packaging.

An experimental between-subjects study that tracked respondents¡¯ eye movements (saccades) towards pack images shown on a

computer screen suggested that standardised packs attracted more

eye movements towards the health warning than did branded

packs, among non-smokers (p = 0.001) and weekly smokers

(p = 0.001), although there was no difference for daily smokers

(p = 0.35) [51]. The impact of health warnings in some studies

varied according to the size, type and position of the warnings

used. A survey of 12¨C14 year olds in Canada and the USA

reported higher levels of recall of warnings on standardised packs

than on branded packs among the Canadian sample but not the

American sample [45]. No study examined gender, age or other

socio-demographic differences in the effect of standardised packs

on response to health warnings.

using a between-subjects design conducted with 14¨C17 year olds in

Australia, respondents¡¯ associations between a particular brand

and the ¡®right¡¯ sort of person (for example, between Marlboro and

a rugged outdoor man) weakened or disappeared when the brand

was presented in a standardised pack, for four out of six

comparisons [46].

Subgroup differences. From the studies which examined

sub-group differences in the appeal and attractiveness of standardised packs, some patterns emerged. Overall, non-smokers and

younger respondents were more affected by standardised packaging. For example, an experimental between-subjects design study

with over 1,000 11¨C49 year olds in Australia found that smokers

were significantly less likely than non-smokers to rate standardised

packaging as ¡®unattractive¡¯ (OR = 0.71, 95%CI = 0.52, 0.98), and

11¨C17 year olds were significantly more likely than 18¨C29 year olds

(OR = 2.51, 95%CI = 1.71, 3.68) to rate standardised packs as

unattractive [32]. The one study which examined gender differences, an experimental within-subjects design involving 836 French

adults, suggested that women found standardised packaging less

appealing than men [35], although it was not possible to calculate

effect sizes from the information given in the paper. No consistent

differences emerged from studies exploring differences in response

by ethnicity or socio-economic status.

Perceptions of harm and strength

Health warnings

Fourteen studies examined whether and how standardised packs

impact on perceptions of the harm and strength of cigarette

products, packs and brands [29,33¨C36,38¨C40,43,44,48,49,52,53].

Three types of outcomes were examined in these studies:

Seven studies examined whether standardised packs increase

people¡¯s ability to notice and recall the health warnings on packs

or whether standardised packs affect the perceived seriousness and

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